Evaluations of the medical home should account for clustering of patients within practices. This paper describes why and how to do this and what samples of patients and practices are needed for studies to achieve adequate statistical power.

Engaging Patients and Families in the Medical Home (PDF Version — 526.27KB) A key element of the PCMH model is engaging patients and caregivers in their care. This paper offers policymakers and researchers insights into opportunities to engage patients and families in the medical home and includes a framework for conceptualizing opportunities for engagement. It also reviews the evidence base for these activities, and offers examples of existing efforts as well as implications for policy and research.

Searchable Databases of Instruments and Measures

Primary Care Measures Databases: Resources for Research and Evaluation Are you looking for instruments and measures to study and evaluate interventions to improve primary care? Use these searchable databases to explore frameworks for measurement, and to identify and compare measures within 4 areas that are critical to primary care improvement. For each database, there is a companion Atlas report available.

Care Coordination Measures Database (PDF Version — 2.2MB) Care coordination is considered a core function in the provision of patient-centered, high-value, high-quality primary care. However, challenges remain in measuring the structural and process aspects of care coordination, as well as its contributions to desired outcomes. The Care Coordination Measures Database (CCMD) is designed to assist evaluators and researchers by providing comprehensive profiles of existing measures of care coordination; organizing those measures along two dimensions (domain and perspective); and presenting a framework for understanding care coordination measurement, to which the measures are mapped. This framework incorporates elements from other proposed care coordination frameworks and is designed to support development of the field. Users of the CCMD can compare more than 90 validated care coordination measurement tools to identify and select those that are most appropriate for their research and evaluation needs.

Clinical-Community Relationships Measures Database (PDF Version — 1.8MB) Understanding primary care’s role in the medical neighborhood and in improving population health, as well as the health of individual patients, is an increasingly important aspect of primary care transformation. Relationships among patients, primary care clinics/clinicians, and community resources can be measured. However this has been an understudied aspect of primary care services. In the context of the Clinical-Community Relationships Measures Database (CCRM Database), a clinical-community relationship exists when a primary care clinician makes a connection with a community resource to provide certain preventive services such as tobacco screening and counseling. The clinical practice and the community resource may engage by networking, coordinating, cooperating, or collaborating. The CCRM Database provides a framework for understanding the measurement of clinical-community relationships and provides information about existing measures, as well as links to resources to improve CCRM research and implementation.

Team-Based Primary Care Measures Database (PDF Version — 857KB) Successful primary care redesign efforts such as the Patient-centered Medical Home require a high-functioning primary care team that delivers team-based care. Team-based primary care holds promise as a way to improve patient outcomes, care processes, and patient and provider experiences of care. However, a better understanding of how teams should function is needed, which in turn requires a strong theoretical conceptual framework and validated measures, specific to and appropriate for use in the primary care setting. Having robust measures of team-based care appropriate to the primary care setting is critical to evaluating and improving team function and patient outcomes. The Team-based Care Measures Database is an inventory of instruments that provides a conceptual framework for team-based primary care and profiles of over 40 instruments for use in research and evaluation.

Atlas of Integrated Behavioral Health Care Quality Measures (PDF Version — 247KB) Integrated behavioral health care can systematically enhance the ability of primary care practices to address behavioral health issues that naturally emerge in the primary care setting, prevent fragmentation between behavioral health and medical care, and create effective relationships with mental health specialists. As greater numbers of practices and health systems begin to design and implement integrated behavioral health services, there is a growing need for quality measures that are rigorous and appropriate to the specific characteristics of different approaches to integration. The IBHC Measures Atlas supports the field of integrated behavioral health care measurement by presenting a framework for understanding measurement of integrated care; providing a list of existing measures relevant to integrated behavioral health care; and organizing the measures by the framework and by user goals to facilitate selection of measures.

Survey Tools

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) program develops and supports the use of a comprehensive and evolving family of standardized surveys that ask consumers and patients to report on and evaluate their experiences with health care